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At the heart of general practice since 1960

Unexpected

benefiT

from helping

the homeless

Dr Peter Moore's practice runs a clinic for homeless people which generates a profit as well as providing a valuable service to the community

As a rule, altruism does not pay the bills. But our PMS project to help the homeless has achieved the impossible. I can generate income and still feel like Mother Teresa.

The idea for the clinic came after a PCT meeting in 2002. The PCT was under pressure to provide a service to the homeless and we needed enough income to support another partner. A PCT manager suggested we take the service on. I was already keen on the idea and had even been to a few abortive meetings.

After discussions with the PCT we agreed to provide the service as a PMS pilot separate from the practice. The PCT already had some proposals which, unlike real pilots, had failed to get off the ground. We were to offer the same personal medical services as we do to all registered patients.

The plan was to improve access to primary care for the homeless, offer high-quality

general medical services and offer continuity of care through a co-ordinated holistic approach.

But perhaps the most important role was to encourage the successful resettlement of the homeless into housing.

After some homework the PCT worked out that we would be serving about 300 patients a year. Figures from other homeless PMS projects suggested the workload would be about three times that of other patients.

Although we were only planning two clinics a week, the patients would be registered with us. We would have the same commitment for the whole week as with all our other patients.

We also needed to be clear what 'homeless' meant. Legally it is defined in the Housing Act 1996. In reality the Homeless Centre knew who were homeless and we would not waste time debating with patients whether they were entitled to use the service. But we did not plan to take all the problem patients in the town.

There would be an agreed payment of £30,000 a year offered by the Department of Health, and the clinic could be run at the homeless centre. The Homeless Charity would provide a receptionist for the clinic. We provided medical equipment and the Homeless Charity provided the buildings.

One-off costs

The room was in a separate building from the hostel. The ground floor of a Victorian terrace was converted to include a surgery, administration offices and an entrance area. Patients wait in the entrance area and

the door into the rest of the building has a keypad.

In the surgery we provided basic medical equipment such as the otoscope, ophthalmoscope and sphygmomanometer. We also needed a couch, a cabinet for forms, blood-taking equipment and basic dressings and a lockable desk. Finally there was a small fridge. Our equipment came to just over £5,000. Another £2,000 was paid out of the PMS budget to provide a laptop computer, printer and phoneline. But we knew that all these set-up costs one be one-offs.

We were finally ready to go. Initially it was agreed we would provide two surgeries a week, run by myself and one other partner. Eventually, when we appointed a new partner, this increased to three surgeries a week using three doctors. From early on we knew that continuity of care was vital. By using the same doctors the patients would learn the rules and we could be consistent.

Notes are kept on the laptop which we keep at the surgery. We download the

registered homeless patients and take it to each clinic.

Although it allows us to keep computerised notes and print prescriptions, there are drawbacks. The downloaded notes do not include scanned letters. This was not

only inconvenient but without the letter we might not believe the patient who says 'When I saw the doctor at the hospital he said you should give me diazepam'.

And we did lay down some rules. Doubtless if I had suffered the abuse and problems in childhood that some of our homeless patients suffered I would also be on the street injecting heroin.

But helping these patients does not mean giving them what they want.

Had we started by offering dihydro-codeine and benzodiazepines we would have had a queue the length of the street. We would also not have the time to provide other medical care.

Avoiding confrontation

I was impressed by the quality of the staff at the centre. As well as being genuine, caring people, they are not naive. From the leaflets and notices and from our actions we have made it clear that we do not prescribe benzodiazepines or opiates.

We refer to the drug abuse clinic for methadone programmes. This can lead to confrontation but our patients know the rules and, after a while, know not to ask.

By leaving substance misuse problems to the experts we have time to deal with other, serious pathology. There have recently been several cases of TB. I've discovered a type 2

diabetic and treated numerous cases of infected injection sites.

Prevention also matters and we offer hepatitis B, pneumonia and flu vaccinations.

In the first 11 months we registered 182 patients and had 892 appointments in the clinic ­ 150 of these were men with the majority, 132, between 18 and 40.

Although we are based near the hostel, only 18 per cent of patients were from the hostel with 83 per cent being of no fixed abode. Fourteen months after starting the clinic the pilot became permanent. By 18 months we had registered 1,548 homeless patients.

The work also dovetails with my other job as a police surgeon. The police always seem surprised I know so many of their regulars. And I am surprised at the regulars' attitude to me.

Even after a 'free and frank' discussion about a prescription in the morning clinic they greet me in the cells with: 'Hi, doc. How are you doing?'

Peter Moore is a GP in Torquay, Devon

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